Technology and product reviews

TECHNOLOGY UPDATE:
Rediscovering alginate dressings

It is approaching 30 years since the first commercially available alginate

wound dressing was launched in 1983. This review revisits this group
of wound dressings and traces their development, mode of action and
use in clinical practice. The author concludes by posing questions about
Author:
the future for alginate dressings and identifying unanswered questions
Michael Clark related to their role in wound healing.

INTRODUCTION  Welding rods

References
1. Thomas, S. Surgical Dressings
and Wound Management. 2010;
Medetec Publications, Cardiff.
2. Wolters Kluwer Health. Seaweed.
Available at: http://www.drugs.
com/npp/seaweed.html (accessed
11 March, 2012).
3. McHugh, DJ. Production,
properties and uses of alginates.
Available at: http://www.fao.org/
docrep/X5822E/x5822e04.htm
(accessed 11 March, 2012).
While the use of alginate wound dressings dates
back 30 years there are anecdotal reports of the
use of seaweed to treat wounds dating back to
Roman times. In folklore seaweed was also said
to have been used by sailors to stem blood loss
and by doctors in 18th century Scotland to drain
abdominal wall abscesses[1-2] . While interesting,
these anecdotes are difficult to verify through
primary sources.
After the second world war, the use of alginate
dressings as haemostatic agents was reported
both in vitro and in clinical studies. They were
also used in wound healing, initially in surgical
wounds then in accident and emergency
departments, leading to a widespread use of
alginate dressings in surgical specialities across
70 UK hospitals[1].
BACKGROUND
Alginates are extracted from a variety of
species of seaweeds, most notably:
 Laminaria (mainly harvested in Scotland,
Ireland, Norway, France, China, Japan and
North and South Korea)
 Macrocystis (harvested in North America)
 Ascophyllum (harvested in inter-tidal areas
in Scotland, Ireland and Canada)[3].
The manufacture of alginates was first
described in the late 1800s, although
commercial production began in the 1930s[2],
with alginates used for a wide variety of
applications, including:
 Textile printing
 Food
 Paper
 Pharmaceuticals.
However, no more than 4% of the
commercial production of alginates in the
1930s was used in wound healing[3].
The adoption of alginate dressings was
effectively halted in the early 1970s when
cheaper materials replaced alginate within
the textile printing industry, thus making
the limited use of alginates in healthcare
commercially non-viable[1].
An upsurge in the use of alginates in the
early 1980s arose through a growing interest
in the treatment of acute and chronic wounds.
Between 2011 and 2012 there were 19 different
alginate dressings available in the UK[4].
MAKING ALGINATE DRESSINGS
When alkaline is extracted from the seaweed
and subsequently filtered, alginic acid is
produced. Alginic acid is a linear polymer with
two monomers (β-D-mannuronic acid and
α-L-guluronic acid). The monomers are joined
together in one of three chains:
 All β-D-mannuronic acid (M group)
 All α-L-guluronic acid (G group)
 Alternating units of β-D-mannuronic acid
and α-L-guluronic acid (MG group) [3].
Different seaweeds give rise to varying ratios
of M, G and MG groups within the alginic acid,
with seasonal changes in the ratio of M to G
groups also seen within species[3].
The alginic acid is then mixed, either with
sodium carbonate or sodium hydroxide, to
form sodium alginate. If this is forced under
pressure through fine apertures into a solution

24 Wounds International Vol 3 | Issue 2 | ©Wounds International 2012

 Technology and product reviews
Page Points
1. Alginates are extracted from a variety of
species of seaweeds.
2. Probably the major reason for selecting
an alginate dressing is to manage wound
exudate.
3. Alginate dressings are manufactured in a
range of presentations from flat sheets to
rope and ribbons.
References
4. MA Healthcare Ltd. Wound Care
Handbook 2011–2012. MA Healthcare
Ltd, London.
5. Richards AJ, Hagelstein SM, Patel
GK, Ivins NM, Sweetland HM, Harding
KG. Early use of negative pressure
therapy in combination with silver
dressings in a difficult breast abscess.
Int Wound J 2011; 8(6): 608–11.
6. Opanson S, Magnette A,
Meuleneire F, Harding K. Askina®
Calgitrol® Made Easy. Wounds Int
2012; March 3(1).
7. Chrisman CA. Care of chronic
wounds in palliative care and end-of-
life patients. Int Wound J 2010; 7(4):
214–35.
8. Sweeney IR, Miraftab M, Collyer
G. A critical review of modern and
emerging absorbent dressings
used to treat exuding wounds.
Available at: http://onlinelibrary.
wiley.com/doi/10.1111/j.1742-
481X.2011.00923.x/abstract
(accessed 8 May, 2012).
26 Wounds International Vol 3 | Issue 2 | ©Wounds International 2012
of a calcium salt, fibres of calcium alginate
are formed. This provides the foundation for
alginate wound dressings[1-3].
Alginate solutions will react with many divalent
or trivalent cations to form gels, with the nature
of the gel strongly dependent upon the mix of
M, G and MG groups in the alginate. Alginates
that are high in M groups have a flat ribbon-like
molecular appearance while areas high in G
groups have a much more buckled chain shape.
These differences in molecular appearance
affect gel formation, with high M alginates
forming gels quicker, with a softer and more
elastic gel than that produced by a G-rich
alginate, which holds calcium and forms a gel
slowly[3]. G-rich alginates form gels slowly as the
buckled shape acts as an 'egg box' into which
the calcium ions are packed[3] and held strongly
(chelated) by the structure of the tetrahydropyran
ring of the α-L-guluronic acid monomer and the
presence of hydroxyl oxygen atoms[1].
To accelerate gel formation, a mix of sodium
alginate and calcium alginate fibres are
incorporated into an alginate dressing, with the
sodium alginate added to accelerate the gelling
process. Therefore, alginate dressings may vary
both in their composition of calcium alginate
and sodium alginate fibres, but also in the
proportion of M and G groups present within
each of the two alginate fibres.
INDICATIONS AND
CONTRAINDICATIONS
Alginate dressings have three main
characteristics that influence their indications
for use. These are their ability to:
 Provide a moist environment at the wound
bed
 Absorb exudate
 Achieve haemostasis[5].
In addition, they are able to reduce wound pain,
lower the bio-burden of the wound, reduce odour
and absorb proteinases[6-8]. If there is prolonged or
atypical inflammation then the wound produces
abnormally high levels of proteinases, which
have a detrimental effect on cell proliferation and
growth factor production. Therefore, absorption
of the proteinases into the wound dressing
potentially lowers the elevated proteinase level
and its detrimental impact on the healing process.
There are some contraindications for the use
of alginate dressings including:
 Dry wounds
 Wounds with minimal exudate
 Surgical implantations
 Allergies to any components of the
dressing
 Third degree burns.
In addition, great caution should be taken
when alginates are used in the dressing of
tumours with friable tissue, which will have
exposed blood vessels, as removal of the
dressing may cause fresh bleeding.
TYPES OF DRESSING
Alginate dressings are manufactured in a
range of presentations from flat sheets to rope
and ribbons[4]. Flat sheets tend to be used for
superficial wounds with the rope and ribbon
versions used to lightly pack cavity wounds.
Probes are included in some alginate dressing
packs to help with packing cavities. However,
packing cavities is not recommended if the
opening of the wound is smaller than the
width of the probe[4].
In addition, there are super absorbent and
self-adhesive versions of alginate dressings[4].
If the alginate dressing is not self-adhesive the
use of a secondary dressing will be required
and selection of this secondary dressing may
affect the performance of the alginate dressing.
WHY SELECT AN ALGINATE?
The major reason for selecting an alginate
dressing is to manage wound exudate as it
is claimed that they can absorb 15–20 times
their own weight in wound fluid[4]. Given this
capacity, it would appear prudent to use a
second absorbent dressing, such as a pad
or foam dressing as the secondary dressing
when alginates are used. Although alginates
can absorb much of the exudate produced by
a heavily exuding wound, some wounds may
exceed the dressing’s capacity for fluid uptake.
Therefore, a secondary absorbent dressing
can be used to contain any excess exudate.
However, semi-permeable films have also been
used as secondary dressings. A film dressing
might be used for a wound exuding less fluid,
which would not require an additional (and
more expensive) foam dressing.
When an alginate dressing comes into
contact with wound exudate there is an ion
exchange between the calcium ions in the
alginate and the sodium ions in blood or
exudate. When sufficient calcium ions are
replaced by sodium ions, the alginate fibres
swell, partially dissolve and form a gel.
The chemical composition of the alginate
dressing also impacts on the dressing's ease of

removal from the wound. G-rich alginates will only
swell slightly during use and can be removed as an
intact dressing, while dressings high in M alginates
will swell to a greater extent and dissolve, allowing
them to be removed through irrigation.
Alginates can be used in a variety of wound
types where exudate is present, including:
 Pressure ulcers
 Venous leg ulcers
 Diabetic foot ulcers
 Post-operative wounds
 Cavity wounds
 Traumatic wounds
 Malignant wounds
 Pilonidal sinus wounds
 Donor sites
 Partial thickness burns [6-12] .
Generally, alginate dressings can be left
in place for 5–7 days. However, the dressing
should be changed when it has reached its
capacity for absorbing wound exudate. This is
normally indicated by ‘strike through’ of fluid to
the secondary dressing. In the case of infected
wounds, daily inspection of the wound bed
may be required.
If the saturated alginate overlaps onto
the periwound skin it can cause maceration,
therefore, clinicians should cut the alginate
to the shape of the wound and apply a
periwound skin protectant (such as a no-sting
barrier film). Some alginate manufacturers
recommend placing the dressing over the
wound and the periwound skin with no
requirement to cut the dressing to shape[5] — if
in doubt, the clinician should always follow the
manufacturer's instructions. As the volume of
exudate reduces there is always the potential for
the alginate to adhere to the wound bed if not
saturated with wound fluid. In these situations
the alginate should be moistened prior to
removal and an alternative dressing used to
achieve moisture balance at the wound bed.
FLUID-HANDLING PROPERTIES
Absorbency should be reported as fluid uptake
2 Reactive Delphi procedure. Part 2:
per standard dressing area (100cm ) rather
than by dressing weight, given that dressings
are supplied in a standard size rather than by
their weight[13]. On this basis, the absorbency
of alginate dressings may range[1] from 16.16
2
grams/100cm to 24.7 grams/100cm with
2
absorbency also reduced where compression
bandages are used[1] (compressed dressings
have less capacity for fluid uptake, probably
due to changes in their physical shape).
If the alginate is used to control bleeding
Technology update Rediscovering alginate dressings
it should be removed once haemostasis has
been achieved, otherwise the blood-soaked
dressing will dry out and adhere to the wound
bed making removal difficult and potentially
painful for the patient. Alginate dressings are
not recommended as a treatment for wounds
that are bleeding heavily. These require
alternative methods to achieve haemostasis,
such as diathermy and cautery.
SILVER IN ALGINATE
DRESSINGS
Alginate dressings have been combined
with other materials, for example,
carboxymethylcellulose, zinc and silver[4]. There
has been considerable interest in combining
silver and alginate dressings since the addition
of silver results in increased antimicrobial activity
when tested in laboratory conditions[14-16]. This
would suggest that the alginate dressings
containing silver may be suitable for infected
wounds. However, they should be used
according to general best practice guidance for
antimicrobial dressings[17], which states that for
the majority of patients, the initial prescription
should normally be for 14 days with a formal
review of treatment objectives at around seven
days. A review should be conducted at each
dressing change by a qualified clinician, and
no prescription should extend beyond 14 days
without discussion with a local specialist unless
previously agreed or indicated by clinical need.
RELEVANT LITERATURE
Thomas[1] provides an excellent review of
the use of alginate dressings (along with a
wide range of other dressing materials) and
this source should be considered as a basic References
introduction to the use and evaluation of 9. Clark R, Bradbury S. Silvercel
wound dressings. Non-Adherent Made Easy. Wounds
Int 2010; 1(5): 1–6.
The commercial production and basic
10. Harris CL, Holloway S.
chemistry of alginic acid and the alginates has
Development of an evidence-
also been discussed in depth by McHugh [3], while based protocol for care of
two recent Cochrane reviews detailed the role pilonidal sinus wounds healing by
of alginate dressings in the treatment of diabetic secondary intent using a modified
foot ulcers [18–19]. Given the paucity of randomised
methodology, analysis and results.
controlled trials that have compared alginates Int Wound J 2012; 9(2): 173–188.
(and other wound dressings), neither review was 11. Higgins L, Wasiak J, Spinks A,
able to reach a definitive conclusion regarding Cleland H. Split-thickness skin
the value of alginate dressings in diabetic foot graft donor site management:
ulcer care, with one stating that: 'Currently, there a randomized controlled trial
comparing polyurethane with
is no research evidence to suggest that alginate calcium alginate dressings. Int
wound dressings are more effective in healing Wound J 2012; 9(2):126–131.
foot ulcers in people with diabetes than other
types of dressing, however, many trials in this
field are very small.'
www.woundsinternational.com 27
 Technology and product reviews

FUTURE DEVELOPMENTS
Alginate dressings have been in clinical use since
the mid 1940s and in commercial production
for almost 30 years. However, alginate dressings
Page Points appear to have lost ground to other wound
1. Alginate dressings have been in clinical use since the 1940s dressings that also absorb exudate — while there
are 19 alginate dressings available in the UK,
2. However, alginate dressings appear to have lost ground to other wound dressings that also absorb exudate —
there are 65 foam dressing products[4]. Recent
while there are 19 alginate dressings available in the UK, there are 65 foam dressing products
surveys of dressing use show relatively low use of
3. This may simply reflect that many wounds are producing less exudate, thus not prompting the use of an alginate dressings compared with foam products,
alginate dressing. However, it may also reflect an opportunity for renewed interest in alginate use for example, Vowden and Vowden [20] noted that
across one English health care district (Bradford),
87 pressure ulcers were dressed with a foam
product while only five were covered with an
alginate dressing. This may simply reflect that
many wounds are producing less exudate, thus
not prompting the use of an alginate dressing.
However, this may also reflect an opportunity for
renewed interest in alginate use.
In the future it may be feasible to achieve
increased fluid-handling capacities in alginate
dressings with additional benefits such as
antimicrobial capability, given the ability
to introduce silver and other components.
Further development of alginate dressings
may also lie in exploring other areas where
they may interact with wound healing. In 2010,
Thomas[1] posed a number of questions, which
if addressed might strengthen the role for
alginate dressings in wound management:
 Can the chemical composition of alginates
be related to healing and wound infection
References rates?
12. Ravnskog F A, Espehaug B, Indrekvam K. Randomised clinical trial comparing Hydrofiber  Do alginates rich in mannuronic acid
and alginate dressings post-hip replacement Journal of Wound Care 2011; 20(3) 136–142. stimulate the production of cytokines?
13. Thomas S. Observations on the fluid handling properties of alginate dressings. Pharm J  Do alginates with a high mannuronic
1992; 248: 850–851. acid content absorb bacteria, proteolytic
14. Wiegand C, Heinze T, Hipler U (2009) Comparative in vitro study on cytotoxicity, enzymes and toxins?
antimicrobial activity, and binding capacity for pathophysiological factors in chronic wounds  Are alginates rich in mannuronic acid help
of alginate and silver-containing alginate. Wound Repair and Regen 17(4): 511–21.
treat infected or malodorous wounds?
15. Percival SL, Slone W, Linton S, Okel T, Corum L, Thomas JG (2011) The antimicrobial efficacy To these could be added questions concerning
of a silver alginate dressing against a broad spectrum of clinically relevant wound isolates. Int
Wound J 8: 237–43.
the value of using alginate dressings in exudate
that contains blood.
16. Hooper SJ, Percival SL, Hill KE, Thomas DW, Hayes AJ, Williams DW. The visualisation
and speed of kill of wound isolates on a silver alginate dressing. 2012; Available at: http:// Positive answers to these questions should
onlinelibrary.wiley.com/doi/10.1111/j.1742-481X.2012.00927.x/abstract (accessed 8 May, lead to an increased interest in, and use of,
2012). alginate dressings and may form the basis for
17. Best Practice Statement: The use of topical antiseptic/antimicrobial agents in wound new research and clinical studies. Thirty years
management. 2nd edition. 2011; Wounds UK, London. after the first commercial alginate dressing,
18. Dumville JC, O'Meara S, Deshpande S, Speak K. Alginate dressings for healing diabetic these are new areas of investigation that
foot ulcers. Cochrane Database of Systematic Reviews 2012; Issue 2. Art. No. CD009110. DOI: could help blend the composition of alginate
10.1002/14651858.CD009110.pub2.
dressings, thus achieving improved patient
19. Dumville JC, Deshpande S, O'Meara S, Speak K. Hydrocolloid dressings for healing diabetic
outcomes.
foot ulcers. Cochrane Database of Systematic Reviews 2012; Issue 2. Art. No. CD009099. DOI:
10.1002/14651858.CD009099.pub2.
20. Vowden KR, Vowden P. The prevalence, management, equipment provision and outcome
AUTHOR DETAILS
for patients with pressure ulceration identified in a wound care survey within one English Michael Clark, PhD, is Visiting Professor in
health care district. J Tiss Viab 2009; 18(1): 20–26. Tissue Viability, Birmingham City University,
Birmingham, UK

28 Wounds International Vol 3 | Issue 2 | ©Wounds International 2012